Tuesday, September 28, 2010

Leaders in Primary Care: Interview with Family Nurse Practitioner Catherine Johnson, RN, FNP, PhD

As we peruse the patient care challenges in Ohio and the nation, we notice 400,000 to 500,000 Ohioans without a primary care physician.  In Greene county, where I practice, 51/2 FTE family physicians have left private practice in the last 17 months.  That leaves roughly 10,000 patients without a family physician.  Those persons may now be using urgent care centers and emergency rooms for their health care.  After a while, that becomes too costly and fragmented to be realistic.

The use of physician extenders in primary care has grown in recent years, including physician assistants and nurse practitioners.  Ohio was the 49th or 50th state to pass legislation supporting nurse practitioners.  As President of the Ohio Academy of Family Physicians, I testified for the legislation in the mid 1990's that enabled nurse practitioners to be licensed in Ohio.  Now we have to get the family nurse practitioners to the front lines of patient care in primary care settings.  They are a valuable asset with clinical and  interpersonal skills that are much needed.  The majority of the Dr Synonymous Show on 9/28/2010 will be dedicated to interviewing Catherine Johnson, RN, FNP, PhD a family nurse practitioner who has practiced and educated nurses and nurse practitioner in three states.

Physicians and patients need to better understand how they may relate to FNP's in primary care.  As a member of a family medicine  team, nurse practitioners have shown high levels of team and leadership skills.  We need them to help shore up a besieged and frustrated  family physician community.
Tune in to Blogtalkradio.com/drsynonymous for the live interview Tuesday 9/28/2010 at 8 PM ET or the same site 24/7 to listen to the podcast.

Dr Synonymous Show September 28, 2010
Introduction and Welcome.  Special greetings to those listening from Denver at the AAFP Congress
Best wishes to Ken Bertka, MD for a successful candidacy for President-Elect of the AAFP.  Go Ken!
Disclaimer:  We're not practicing medicine on the show.  See your own  family physician for your best care.
Show Overview
Happy Birthday to anyone born on this day (including Mrs Synonymous)
Hi to those in chat room
Salute to patients
                Patient Blog: Living It, Loving It at blogspot.com with music
Medical Blog: Pallimed hosting Grand Rounds Vol 6.52 9/21/2010
Medical Factoids
Introductory Comments about nurse practitioners- my support of legislation in Ohio
Introduction Dr Catherine Johnson, RN, Family Nurse Practitioner, PhD
Questions for Dr Johnson
                So you’re back in Central Ohio, what are you doing professionally now?
                What kind of educational experiences have prepared you for this?
                You were a VP for Nursing of Columbus Children’s Hospital for six or seven years, what was that like?
                Why did you leave that position?
                What was next?
How did you come to join the faculty at WSU?  What programs and projects were you involved in when in the Dayton area?
How did your family life relate to leaving WSU and the Dayton area?
How many children and grandchildren are you blessed with now?
What’s it like caring for twins?
Any questions from the chat room for Dr Johnson?
Let’s hear about the University of Arizona.  When did you go west and what did you do?
OK, there is a New Mexico component, too.  What did you do in NM?
Ohioans have heard a lot about border tensions in AZ and NM, what did you notice when you lived there?
Would you comment on your passion for migrant health care.
What about the doctoral degree for all nurse practitioners:   Can you explain that for our listeners?  I’m an enthusiastic supporter of nurse practitioners, but I’m worried that the doctoral degree might dilute the clinical capacity of FNP’s because of administrative opportunities.
What kinds of scholarly work have you completed in academic settings?
What do you think is going to happen to patients and their primary care in the next few years?
You have seen and done a lot, what’s your dream for the next phase of your career?
What is going to happen to primary care patients? And primary care nurse practitioners?
Any  other comments that you have for our listeners?
Thanks again for sharing with the Dr Synonymous Show, Dr. Johnson / Catherine.  We will continue to work together.
Next week, I’ll expound on more aspects of the Human Centered Health Home and life in family medicine.
This is Dr Synonymous, Good Night!

Tune in to blogtalkradio.com/drsynonymous to hear the entire show with the interview. 

Sunday, September 26, 2010

Family Medicine: Learning from Marcus Welby and Dog the Bounty Hunter

Television abounds with Crime Scene Investigator shows, like every channel once or twice a night has a CSI type show (NCIS- Naval Criminal Investigative Services- had a "marathon" two nights ago so we could reaffirm that there are a lot of killers in the Navy).  Naturally, as a family physician, I have to watch lots of TV to keep informed of what "entertainment" exposures my patients might have.  The non-CSI shows seem to be peppered with Law and Order reruns and even some "new episodes", featuring murder and perversion.  Lawyer shows seem to abound also, with more murder and perversion.  Medical shows such as Grey's Anatomy and House are more sparse and feature a lot of interpersonal dilemmas among the characters, including the dilemma of Dr House illegal procurement and use of, and dependency on, opiates (Vicodin).

I flash back to the 1960's and 1970's when I was getting part of my inspiration to become a family physician from the television characters Marcus Welby, MD (played by Robert Young) with his younger assistant Dr Steve Kiley (played by James Brolin) who rode a motorcycle, Ben Casey (played by Vince Edwards) and Dr. Kildare (played by Richard Chamberlain).  There was no physician drug abuse and no emphasis on murder or perversion.  Dr Welby had unlimited time for patients and a caring, understanding office nurse, Consuelo Lopez (played by Elena Verdugo) who added balance to each episode.  The show did introduce information about common diseases and also dealt with touchy issues such as impotence, depression, drug addiction, mononucleosis and many others.  Dr Casey always wore what we called "a Ben Casey" shirt.  Both he and Dr Kildare  spent a lot of time in hospitals and had various flirtations with a variety of starlets, but no drugs or sex.  The Dr Kildare theme song, "Three Stars Will Shine Tonight" was a '60's hit, inspiring romance in teens across America.  Times change.

Beyond many commendable religious shows on TV, who can inspire us now on television?  Who gives us words to live by?  I've started to float across TV land searching for truth and meaning or mindless entertainment. I find a few shows worthy of positive comments including two back to back classics on the History Channel, "Pawn Stars" and "American Pickers".  The first is about a Las Vegas Pawn Shop operated by a grandfather, father and son.  They reveal their thinking of how they value items that people want to sell and show a delightful mentoring attitude in their three generational interactions.  The items featured on the show are often historic, with frequent outside expert consultations used to evaluate the items.  The second, "American Pickers" entertains on the same night and channel with two antique store partner/ owners traveling to the individual collections and barns of America.  They pick over the old items and make offers to the owner for useful antiques to sell in their store.  They also reveal their thoughts about value and negotiations with the owners.  Both pawn and picker store owner teams close every sale with a handshake and simultaneous eye contact, role-modeling a time-honored behavior of buyers and sellers.

A surprise for me is my enjoyment of "Dog the Bounty Hunter" on the A&E channel.  Dog, aka, Wayne Chapman, runs a family business to run down and bring in, to the legal authorities, persons who failed to show up for their court dates.  The Chapman family members are bounty hunters.  Dog has long blond hair and thick shades with built in hearing aids.  He wears a cross suspended on a chain around his neck.  He usually wears black leather trousers and vest over a mostly bare chest.  He smokes.  He loves Beth, his current wife and his children.  Dog as a young man ran afoul of the law and did some jail time, which he frequently reveals to criminals they apprehend.  His team tracks down the lawbreaker using family systems information and communication via lots of cell phone calls and face to face communication achieved by travel in their Cadillac Escalade vans.  Their understanding about family structure and function seems to provide a shortcut to find the lawbreaker and bring them to justice.

There is often an intense moment at the time of apprehension until the bounty hunter team is guaranteed safety with their prey secured in handcuffs.  Dog and his wife Beth then seem to convert into social workers and missionaries.  They offer the person a cigarette and talk about family while giving the person an opportunity to hug, kiss and bid farewell (for the time being) to their loved ones who are at the apprehension site.  Dog and Beth often apologize to the person they just captured for the amount of force they applied or the tenacity they used during the chase.  They call the person's mother, wife, or husband and let them talk with the lawbreaker.  They then might offer a prayer for their prisoner and then pray with their family of bounty hunters at the end of the hunt just as they did at the beginning with the whole team holding hands.  They connect as humans to humans in a family context acting on and establishing relationships as they go.  They apologize and ask forgiveness as indicated and forgive others quickly.

So how do any of these comments relate to Family Medicine?  These TV characters manifest many important attributes that we might emulate from time to  time.  From the caring and concern of Dr. Marcus Welby combined with therapies that were often unorthodox  according to his younger, tradition- based assistant, Dr. Kiley to the American Pickers and Pawn Stars who negotiate openly and look you in the eye while they shake your hand to seal the deal, we may be reminded of human to human commitment.  We may be reminded of a firm handshake we made with a compelling dream that called us to serve others throughout our medical career.

We might personalize some strategies employed by Dog the Bounty Hunter and his family to pray individually or together at the start of our activities and when they are complete.  We might reflect on the power of the family via its structure, function, richness and the attributes of its members.  We might help our patients to be more aware of their family relationships and commitments.  We might forgive faster and help our patients to reflect on opportunities for forgiveness of self and others.  We might apologize to our patients when necessary.  We might think more about the personal comfort and safety of our patients (but not with tobacco-Dog does have some shortcomings).

Personally as I reflect on the family doctor of my youth, George Martin, MD in Miamisburg, Ohio and the TV doctors who I watched faithfully as a high school student, I feel compelled to find my letter of application to medical school to review my stated dream.  I want to recharge and realign the dream to be consistent with the "upgraded" family physician that I see in the mirror. I want to make sure I have forgiven the doctor in the mirror for his imperfections, prayed for his future and that of his patients and apologized for allowing the misalignment with the dream to go unrecognized for too long.  Thank you Dr. Martin, Dr Welby, Dr. Kiley, Dr Kildare and Dr Casey for inspiration.  Thank you American Pickers, Pawn Stars and Dog the Bounty Hunter for demonstrating attributes in your careers and your relationships that family doctors might emulate.

Quit smoking, Dog!

Friday, September 24, 2010

Another Friday in Family Medicine

Start with senior citizens. A delightful couple with multiple degenerative processes. Issues with their adult children: emotional, financial and life-cycle issues. Issues with medications, price, side effects, prescription needs. "The doughnut hole" for prescription coverage. He shows concern for her and vice versa. Separate styles and separate perspectives on health and health care, all three of us. Seeking common ground as we listen to each other.

An engineer with hypothyroidism and neck pain (from yard work) who has an impressive new superphone.  A twelve year-old girl with mother, child has constipation and school stress due to child's perfectionistic tendencies. Well baby check up on three year old girl who is very engaging and even says Ah when she sticks her tongue out for throat exam (3 year olds almost never can do that).  I congratulate her on the "Ah" skill.

Mother and daughter with stress and depressed mood. Medicine or no medicine to add to the ongoing counseling. Depends on many variables. Eating change, addition of Omega 3 fish oil, Multivitamin, B complex 50 and vitamin D3, and sleep discussion after info gathering about the mood. Complex situations, simple recommendations. Then follow up visit in 2-3 weeks, depending.

Lunch: 2 tablespoons crunchy peanut butter, large glass water, one can chicken noodle soup (microwave).  Review letters from other physicians, lab results and imaging studies of patients while eating. Check Facebook, email and Twitter while eating.  Another huge glass of water then XS Energy Drink.  Off to see afternoon patients.

Hospital follow-up patient:  Review hospital generated list of going home meds with patient.  Three of them used brand name that patient didn't know, since patient takes generic meds.  This is how people get readmitted to hospital.  Drs in hospital write for same drug with different name, patient gets confused, may or may not take the medicine as expected.  Has the generic at home and the new prescription from the hospitalist.  If patient frail elderly, may take the new drug and the old generic that is same, resulting in double dose of med.  Patient gets ill, may go back to ER if really bad or see family doctor for illness (dizzy, SOB, nausea, abdominal pain, etc.) a few days before scheduled hospital follow-up visit with same family doc.  Acute visit gets slotted for less time and patient gets less thorough evaluation by family doctor, etc.  Cascade of dilemmas may happen when we change drug names on patients.

Sometimes, frail elderly transferred from hospital to rehab center before going home, getting a new set of generic drugs than the list given at hospital discharge. Then new list given from extended care facility where rehab occurred, listing the facility "favorites" that replaced the list from the hospital.  Patient's adult child/ caretaker fills new rx from new list and that leads to duplication of many pre-hospital meds unless the people involved are really attentive.  With EMR, some of this may be caught earlier and corrected, but with 12-13 drugs plus vitamins and supplements, it's a challenge to keep the meds straight.  This is another important example of how family physicians save lives, re-admissions and money for patients and tax payors.

Walk in patient:  family stress, uncontrolled diabetes and  upper back strain from over use caused by angry response to grandson's lying and chemical dependency.  Patient coped with the stress by vigorous yard work leading to the overuse syndrome, and enough pain that we can work with her to get a different stress reduction strategy.  Adjust Lantus insulin dose to get the diabetes better controlled.  Recommend name of counsellor in response to patient realization that professional mental health support will benefit her.

Get agreement on follow up interval for upper back and diabetes, schedule fasting blood tests, write one prescription for short term  $4 NSAID and list steps for self care upper back.  Fill out encounter form with billing info and dates for labs and follow-up visit. Touch her shoulder with response to her feelings ("You're relieved that you've decided to move ahead with a new coping strategy") and encouragement that "You can do this.  You're tough." 

Only eight more people to see this afternoon...Onward.

Monday, September 20, 2010

Family Medicine: Learning from the Military

As a cadet at West Point, I recall having to analyze the major military battles in history using the Principles of War, United States Army. Once I became a civilian after five years on active duty and one year of reserve duty, I didn't recall much about the Principles of War until joining the faculty at The Ohio State University College of Medicine. Then I needed to refer to them again as politics heated up at my alma mater. Now , as we enter a challenging era in health care with massive change upon us, I refer back to the Principles of War to analyze and plan responses to our situation. By us, I mean patients and their family doctors.

Business uses of the nine principles were nicely explored in a 1992 book titled Duty, Honor, Company: West Point Fundamentals for Business Success by Gil and John Dorland, brothers who graduated from the US Military Academy at West Point in the Viet Nam era.  Military references to the nine Principles of War include the Combat Leaders Field Guide, Department of the Army FM 22-100 Military Leadership and FM 100-5 Operations.  I'm not aware of any medical works about using the Principles of War.  We're ready for some applications of the Nine Principles of War to health care.

1. Objective:  Direct every military operation toward a clearly defined, decisive , and attainable objective.

2. Offensive:  Seize, retain and exploit the initiative.

3. Mass:   Mass the effects of overwhelming combat power at the decisive place and time.

4. Economy of Force:  Allocate minimum essential combat power to secondary efforts.

5. Maneuver:  Place the enemy in a position of disadvantage through the flexible application of combat power.

6. Unity of command:  For every objective, ensure unity of effort under one responsible commander.

7. Security:  Never permit the enemy to acquire an unexpected advantage.

8. Surprise:  Strike the enemy at a time or place or in a manner for which it is unprepared.

9. Simplicity:  Prepare clear, uncomplicated plans and  concise orders to ensure thorough understanding.

Imagine that the enemy is the H1N1 influenza.  You might be able to recognize how each of the principles might apply.  What if the enemy is biased information from a professional or patient group or the pharmaceutical industry or misdirection of scarce valuable health care resources by overemphasis on technology?  Think of the benefits and detriments of looking at our health care situations with these principles.

We'll discuss these and focus on one or two on my Blogtalk Radio Show 9/21/2010,  including comments from the chat room.  This is a NON-Combat application of the nine Principles of War.  Think peacefully in your heart.  Peace is good.  (The Viet Nam veteran in me knows this up close and personally).  Peace.

Tuesday, September 14, 2010

Family Medicine Leaders: Interview with Larry Bauer, MSW, MEd Executive Director FMEC, Inc.

Dr Synonymous Show September 14, 2010   http://blogtalkradio.com/drsynonymous
Overview of Show

Patient Blog:  http://SeaSpray.blogspot.com

Medical Factoids:  Family Oriented Primary Care by McDaniel, Campbell and Seaburn

Interview with Laurence C. Bauer MSW, MEd Executive Director Family Medicine Education Consortium, Inc.

Questions for Mr. Bauer:

What’s up with the FMEC, Inc Northeast Regional Meeting this year?  Who will be there?  Who should go?

Comments about the name change from NESTFM?

You’ve seen a lot in Family Medicine and Medical Education since the late 70’s.  What have you learned from your interaction with the masters?  How would you describe your career so far?

What aspects of family medicine education were developed by whom?  How about a little who’s who from your perspective over the years?

What is happening now in Family Medicine? FM Education?

How does the innovators network relate to family medicine?

What innovation is needed now in family medicine and medical education?

What fellowships in family medicine have you started or related to?

What role do fellowships have for the future?

What did you do in your first position in the Department of Family and Community Medicine in PSU MS Hershey Medical Center?

You are a grandfather now, how is that working out?

How might social media like Facebook, Twitter, Linkedin, Youtube and this show on Blog Talk Radio benefit Family Medicine, family physicians and patients? 

A social media network is now open courtesy of Mike Sevilla, MD, http://fmec2010.blogspot.com/ for use  before and during activities at the FMEC, INC meeting in Hershey.  Family medicine educators and residents are encouraged to use this site as a springboard for a FMEC, Inc Social Media Network.  How might that fit into the present and future?

Humor in family medicine?

How can medical students sign up for the FMEC, Inc Northeast Regional meeting?  www.fmec.net

Thank you for being with us tonight, Larry.  Good luck!
Next week Dr Synonymous discusses leadership strategies in family medicine that evolve from military models of leadership and human models of functioning.
Thanks for being here with us.
This is Dr Synonymous.  Good night

Saturday, September 11, 2010

A Wedding Prayer for Renee and Phil

Heavenly Father,
Thank you for this wonderful day and this time of focus on family, friends and love.  Thank you, God, for the love that connects the hearts of Renee and Phil.  Bless them as they build that love with your guidance.  Allow your Holy Spirit to nurture in them a permanent connection to that which is Holy and True and hold them in your hand for healing when they face illness or adversity. Bless them with joy and fun and let their stresses and disagreements become opportunities to expand their love and commitment.

Holy Spirit, bless the families of Renee and Philip as we celebrate the continuation of our heritage through the marriage vows of this couple.  Let both friends and family members enrich their understandings of life, love, friendship and family as they share stories, traditions and secrets.  Allow us to feel your thanks in our hearts for the love and guidance we have provided to Renee and Phil.  Soften our hearts when we need to forgive, and reward us as we act on our love for each other. God, let the love of Renee and Phil be a force that enriches family and friends and  bless  their parenting potential which is of great interest to many in this room.  Let them always remember those who paved the way for their successful marriage.

Holy Spirit, bless this meal and enable those who share in this celebration to be refreshed by it with more energy to serve you.  Protect us all as we return to our homes and reflect on the joy we have shared.  Lord, bless us all in fun and love and  let us know when we need two toothpaste tubes or two bathroom sinks to maintain a balance in our relationships.
All of which we ask in the name of the great Friend and Master of all, Jesus Christ Our Lord,  AMEN.

Tuesday, September 7, 2010

Family Medicine Leaders: Lori Heim, MD President of The American Academy of Family Physicians

Lori Heim, MD is the current President of the American Academy of Family Physicians.  She has helped the AAFP to continue to be in the health care and the healthcare conversation (one word just refers to money while two refers to the care of people).
Dr Heim represents us in many ways.  On September 7, she is a special guest on the Dr Synonymous Show on blog Talk Radio. (www.blogtalkradio.com/drsynonymous)

Dr Synonymous Show September 7, 2010 8 PM Special Guest Dr Lori Heim, AAFP President

Introduction by Dr Synonymous


Overview of Show

Mention of Patient Blog

Mention of Physician Blog: Dr Synonymous June 9, 2010

Comment on the chat room

Two medical reports from new or review literature

Introduction of Dr Lori Heim, President of AAFP at 8:15 PM ET

Questions may include: Where did you live as a child?

How did you decide to become a physician?

How did you decide on the military service? USAF?

What’s good about military Family Medicine these days?

Did anyone in the chat room serve in the military? Feel free to type in Q for Dr Heim in chat room.

Where were you stationed in the Air force? What did you do?

How about hazardous duty in the Air Force?

Med students are racking up lots of debt these days, what kind of debt forgiveness can they get by joining the military?

The AAFP is such a great group of people, me included. What are the challenges facing the AAFP now? What are the big issues and happenings the Academy expects for the Denver meeting this month? Etc.?

How did the leadership of AAFP make the difficult decisions these last couple years?

Many members were conflicted about heavy handed politics during the health care reform legislative confusion. How do you respond to member concerns about what seemed to be an unfair process at times?

How do you relate to the revelers while concurrently responding to the anger of other members?
(I personally chose to comment on the AAFP web site and on the AAFP Face book site when I had opinions to offer, supportive or unsupportive of the direction of the AAFP leadership about the HC legislation. It was helpful to vent quickly and thank the leaders for their obvious commitment to members and patients.)

Other questions just follow the flow of the conversation and humor is important.

What’s ahead for medical students that will help them to be more family medicine inclined?

What is going to help residents to prepare for what’s next? How do they not get too techy with EHR, PCMH, P4P, etc.? How can they hug patients when a computer is in the way?

Thank you again for being at the Ohio AFP meeting in August. You heard the resolution at the Ohio AFP meeting about commercial interests (with Coca Cola and Pharma concerns emphasized) and AAFP and OAFP. Where will that discussion lead us?

As a leader, what have you learned by leading one of the best groups in America (Dr Synonymous may be biased)? How have you changed during this year? Where does it lead your career?

Are you still having fun?

Any other comments or suggestions for questions you want to be asked?

Thank you Dr Heim for joining us tonite.

Next week’s guest is Larry Bauer, Executive with the Family Medicine Education Consortium, Inc. We’ll hear about an exciting meeting of Family Medicine educators in Hershey PA Halloween weekend. And a lot more.

Thank you for joining us. This is Dr Synonymous. Good Night.

Listen to a podcast of this show at  www.blogtalkradio.com/drsynonymous

Monday, September 6, 2010

Family Medicine: Babies, Immunizations and the Heart of a Mother

Newborn babies and infants are always interesting in family medicine. I even take care of several who were delivered at home, due to parental preference, most of whom I saw in their home (yes, a home visit- they are still fun and meaningful) soon after they were born. My father and aunt were born at home, so I consider home delivery to be a normal process that is chosen by a small number of couples as their preferred birth method.

We also have several home and hospital delivered children whose parents opt not to immunize or to modify immunization schedules for their children.  Five or six of our families came to us because they were evicted from Pediatric practices for their immunization preferences.  These variations on standard immunization protocols are challenging, partly because of the degree of difficulty of understanding immunity and immunizations and partly because of limiting beliefs of patient, physician and society.  None of us have hit belief perfection yet, so we do the best we can in the context of a caring relationship.

How do we analyze the actual understandings of the parents to be able to make their best decisions about immunizations versus diseases?  I don't know, but, when asked, they usually profess to understand what they need to know.  They "own" their children and they have been informed of  their options for immunizations versus no immunizations or some immunizations.  I believe they have the right to decide how to raise their children, informed by the context of their world and its laws.

A parent who chooses not to immunize her two month old infant is here today.  During our interaction about how everything is going with her, the baby's father and the baby, I ask how she is staying informed about the diseases and the immunizations that her child may face over the next few years.  She says she feels that it's best to wait for the "shots", but she's not sure why she knows.  She does not want any more information about the diseases or the immunizations at this visit.  I chart that she does not want to immunize her child at present and that I offered some information about the immunizations and some about the diseases, but she was not interested in the information at present.  I would feel better if she looked at some of the information, but she chose not to read it.  A touch of physician guilt happens, about whether I did my best to share information and about documenting my efforts (for the system that audits my behavior regarding immunizations and can exclude me from participation if I go astray- this takes me away from the best connection with mom and baby for a short time) but then I can feel the contentment in the mom and I have peace, too.  A mother has made a decision about her baby and I honor it.  Her decision from her heart is one of love, a wholehearted love decision. 

The heart of a mother is not well studied electrically or technologically, but it has a huge role in families.  Sometimes, mothers just know in their heart what's right or best.  They can hurt in their "mother's heart" when they can't protect their "babies" (even their adult children).  This isn't a medical issue in our literature, but it is an issue in the world's literature (e.g.,the Bible, music, poetry, art, novels, etc.) and definitely a human issue in families and communities.

I complete the exam of the healthy infant, congratulating the mom on how well she's doing so far and how healthy her baby seems to be.  As I listen to the proud mother talk of her baby and how her own mother is very helpful and understanding, I get a good feeling about the Heart of a Mother.  It is powerful and important in the decision processes of mothers and families.

Medically, we might find more ways to understand and connect with it.

Friday, September 3, 2010

Family Medicine: Sensitive Death Comments

Two patients in one day commented about physicians mentioning death as one of their potential outcomes with serious illnesses, one in an ER and one in an oncologist's office.  The bluntness of the comments surprised me, so I sought clarification of the actual words used to relay the surprising information (to the patients).

I remember calling a physician in the ER to inform them of my patient coming via squad with extreme shortness of breath and a history of DVT (deep venous thrombosis- blood clots in leg veins).  A few hours later a physician in the ER entered the cubicle where my patient and her caretaker daughter waited (now with an IV and oxygen for the patient).  According to them, the physician said, "We have good news and bad news, we've found out what's wrong with you- you have blood clots in your lungs and you could die." He left before they could say a word.  They were stunned.  And afraid.

The other patient is a woman on the mend from breast cancer.  After the surprising mammogram finding of a tumor and the biopsy showing a common cancer with micro-invasion, the patient underwent lumpectomy and met with the oncologist.  The words she heard were to the effect that, "there's an 80% chance that you need no more than what you have already experienced to be cured.  But we want to do radiation therapy and chemotherapy to improve your odds for survival."  The patient agreed and had a recent visit with the oncologist who said.  "I'm glad you got the Chemo and radiation or you would have probably died."

What happened to the 80% chance that the patient was already cured before chemo and RT?  After the comment by her oncologist, she felt like the 80% changed to zero, so now she is only relying on the chances delivered by the chemo and the radiation.  Her brain is not going back to believe in the 80% comment, since the doctor "erased it".  She lost some of her hope for cure.

Hope enhances t cell and natural killer cell function, decreasing the chance for recurrence of breast cancer, according to good studies.  Killing hope should not be a physician skill, even an accidental one.

 "I apologize for my profession,"  I said to both patients.  I'm sorry we don't do better with our communication about risks and benefits of diseases and therapies.  I'm sorry that we sometimes don't have the right words to impart to the patient what they actually need to know.  I'm sorry that we sometimes terrify people.  I hope we get better at remembering Hope which is one of the "drugs of choice" for most ailments.

Thursday, September 2, 2010

Family Medicine: Power Failure

The lights suddenly went out in the exam room where I had just handed my patient the documents to give to the person at the front desk.  The temperature outside was 92 degrees.  It was 12:15 PM.  I looked at the afternoon schedule hanging on the door listing my patients and those of our family nurse practitioner.  As I talked with our medical assistants, we pondered the cause of the power outage.  The office was getting warmer.

I noticed someone on the schedule who was a frail person over 90 years old.  Call her and everyone down to 2:30 and tell them about our power failure.  We'd like to reschedule them.  By 12:40 everyone was in receipt of a call, most to answering machines or voice mails.  Our phones didn't work, so we used personal cell phones to call the patients.  Three of them, as the afternoon progressed, did not know they had an appointment.  Very interesting.

The first three patients showed up and were treated in the one exam room with windows and in our conference room/ kitchen.  At 1:20, with the heat causing me to perspire, a maintenance man came into our building and turned off the lobby alarm, informing us that a car had struck a power pole causing the power outage.  He thought the power would be back on by 1:45.  It was.

When the power fails we have to consider our computer system which houses all our business information and patient lists.  We back it up regularly, so a total failure wouldn't wipe out our important information, like our ability to bill for services rendered and our knowledge of our patients.  We have an electronic health record, Praxis, on the system but we haven't started using it yet.

Refrigerable materials and temperature sensitive items also were high on our concern list with the power failure.  We have a back up site to remove the materials to if the temperature in the refrigerators rises too high. 

With the power back on and several patients canceled (not rescheduled since we need the computers to be able to schedule) we became sluggish for a couple hours.  We reviewed some things about procedures when the power fails and called some people back to reschedule them.  I remembered that I have some charts to review for legibility to send off to an insurance company.  Everything we write on Medicare patients is reviewed by a review nurse once we fax the chart to their company (we have to copy and fax these at no expense to the government contractor that does the review).  This is one of the painful aspects of relating to Medicare which has a huge hassle factor.  No other patient group requires as much scrutiny by regulators.

Congress allowed physician reimbursement for Medicare patients to be reduced by 21.2% four times in the last 9 months, but reversed the reduction each time, currently until November (after elections) when there's a fair chance they'll cut our reimbursement, endangering the very financial survival of thousands of family physicians.  Because of the flaky way Congress relates to Medicare, thousands of physicians across the nation have closed their practices to new Medicare patients (including my office since 1/1/2010).

There is no way that there is near enough capacity to care for the growing Medicare population with the dwindling primary care physician numbers and the repeated disrespect shown to primary care physicians by our health care non-system.  Five and one half family physicians have left my county in the last 16 months, leaving over 10,000 patients without a family physician.  So I fretted a bit about insurance companies and the plight of primary care during the power outage.  One could say that there is a power outage in our health care system much worse than the brief one we experienced in our office.

I gladly delayed the chart review since patients started to show up.  Soon we were back to our normal pace.